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V.1.\ VV/l`IV ll Lt\ll\\VI\IlaL,l\afll/ aati .as Vl'/l flE�l.11l�.\ l <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ktoo I g logq S� Gb$spU � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> JV 4L CH(J <br /> FACILITY NAME .� _oo —� <br /> SITE ADDRESS 7 �� p ' /11 l �L `E n �j C\ �j/'�O <br /> Strae Number Dlreeuon /V/-1 lreal'TFa>me I` t I lCi7t <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nama <br /> CITY STATE ZIP <br /> PHONE#1 EM APN# LAND USE APPLICATION# <br /> (� ) —?o <br /> PHONE#2t�J / ErT. BOIS DISTRICT LOCATION CODE <br /> (AoVh t(�l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �n <br /> JI� 4VQ CHECK If BILLINGADORESS <br /> BUSINESSNAME V p PHONE# EXT' <br /> — S —t vo C A own ex P0 <br /> HOME Or MAILING ADDRESS —J/I./f� / ) &t� ' , - R P FAx# <br /> L-./rel- IV � 1 ) <br /> CITY C\ STATE ZIP !; 20 <br /> BILLING ACKNOWLEDGEMENT: h the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRON'OrNTAL HEALTH.DI±PARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standords, STATE and F . •RAL S. <br /> APPLICANT'S SIGNATURE: <br /> DATE: � 3 <br /> PRO PE R 1)1 BUSINESS OWN F.R I]A1} OPERATOR/MANAGER ❑ O'rIIERAUTNORIZEDACEN-i V t.V 1`1'eV <br /> If Apm.w-i N i A nai the B11LING PART)',proof of andioricafiou tosign is required TFNe <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator ol'the property located at the <br /> above site address. heichy authorize the release of any and all results, geotechnical data and/or ens'irottmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saltie time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ___ _ __EENT <br /> COMMENTS: PAYMENT <br /> RECEIVED 5 <br /> MAR 15 2022 0AOUIN000NTY <br /> I NVIRUNMENTAL <br /> ,AN JOAQUIN COUNTY I1L1UUEMRTMENT <br /> EN...O,MCWAL <br /> HEALTH DEPARIMENS <br /> ACCEPTED BY: f e EMPLOYEE DATE: <br /> ASSIGNED TO: L- P1 QS EMPLOYEE#: DATE: 3 ^ S ^ <br /> Date Service Completed (if already completed): SERVICE CODE: b 1 P/E: k\(3 <br /> 1 0 <br /> Fee Amount: S Z r Amount Paid 1,5 Z _ Payment Date ,3 �s L Z <br /> Payment Type (S6\_ Invoice# C ck# l) 6D 39 Received By: <br /> EHD 48.02-025 a J f I y L 1� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �52'1�110 Gj <br />